Chronic Care Management

Making Every Minute
Count in Your Chronic
Care Management Workflow

Chronic Care Management

Making Every Minute Count

Chronic care management (CCM) is an essential component of achieving long-term health and wellness. This approach involves providing ongoing and coordinated care to people with chronic conditions, enabling healthcare providers to deliver better outcomes and enhance the quality of life for their patients.

However, the statistics on chronic diseases underscore the dire need for better CCM. Chronic diseases account for 70% of all annual deaths, as reported by the Centers for Disease Control. These numbers are heart-wrenching, and they demand a robust response.

Yet the U.S. is already bleeding resources trying to manage the growing problem of chronic diseases. In fact, $3.69 trillion of the nation's annual healthcare expenses go toward managing these diseases. However, despite such efforts, the prevalence of chronic diseases in the U.S. continues to grow steadily by seven to eight million people every five years.

This predicament leaves health professionals wondering, ”How do I start a chronic care management program that works? One that’s sustainable and makes a dent in the problem?” Unfortunately, the issue of financial viability is a daunting obstacle on the path to a successful CCM program. Limited resources and time constraints often make it difficult to successfully launch and maintain programs that deliver on their promised benefits.

In response to this challenge, many healthcare facilities are turning to innovative chronic care management solutions that combine the power of a CCM platform with supplemental and flexible care coordination services. By leveraging the latest technology and providing personalized care for each patient, these facilities are making a substantial impact on the problem of chronic disease management.

Whether you're just starting to build a CCM program or looking for ways to enhance your existing efforts, this article is a must-read. We'll guide you through the basics and show you how to leverage a chronic care model within the framework of value-based care (VBC). By embracing the latest technology and innovative care strategies, the health care system can create more compassionate and effective strategies that prioritizes the needs of patients.


What Are 4 Major Chronic Diseases?

Cardiovascular disease, cancer, chronic respiratory disease, and diabetes diseases are the four major chronic diseases. These diseases are responsible for a significant portion of healthcare spending and are associated with high morbidity and mortality rates. 

CCM can play a crucial role in managing chronic diseases like these. More specifically, here's how a patient suffering from each condition could benefit from CCM:

  1. Cardiovascular Disease - CCM can provide patients suffering from cardiovascular disease with customized care and consistent monitoring of critical health indicators, such as blood pressure and cholesterol levels. Additionally, a patient's care coordinator can serve as an accountability partner in adopting healthy lifestyle changes, like exercise and dietary modifications, to reduce the risk of cardiovascular disease.
  2. Diabetes - CCM is a powerful ally for patients battling diabetes, offering assistance in managing blood sugar levels and monitoring foot health for nerve damage and poor circulation. By mitigating the risk of complications like kidney disease and vision loss, CCM empowers patients to reclaim command over their well-being.
  3. Cancer - With the help of CCM, patients battling cancer can receive comprehensive care coordination between multiple healthcare providers. This includes managing the often difficult side effects of treatment while also offering vital emotional support to patients and their families throughout their battle. A CCM program provides a lifeline to patients, ensuring they receive the personalized care they need to fight cancer with confidence and hope.
  4. Chronic Respiratory Disease - Through CCM, patients with chronic respiratory diseases receive regular monitoring of their respiratory symptoms and guidance on managing their medication and oxygen therapy. Furthermore, CCM can educate patients on avoiding triggers that exacerbate respiratory symptoms. As part of this education, patients can learn about lifestyle changes that promote healthy lung function, such as quitting smoking.


How Do You Create a Chronic Care Management Program? 

Although creating a CCM program is complex, the rewards are immense. Here are some general steps you can take to get your CCM program up and running:

  1. Assess your Facility's Capabilities and Resources - Before starting a CCM program, evaluate your current capacity and resources. Do you have the necessary staff, technology, and infrastructure to implement a CCM program? If the answer is “no” and there's no room in the budget for new staff salaries, consider outsourcing this load to a full-service CCM provider like TimeDoc Health. With dedicated care teams, 24/7 patient support, and helpful tools like enrollment assistance, TimeDoc Health truly simplifies CCM. 
  2. Identify Eligible Patients - After you've secured the proper infrastructure for a CCM program, the next step is finding eligible patients who may benefit from the program. Patients with two or more chronic diseases, or those with high-risk chronic diseases, will likely qualify. What conditions are eligible for CCM? According to the Centers for Medicare and Medicaid Services (CMS), numerous conditions are eligible—Alzheimer's, arthritis, cancer, heart disease, depression, diabetes, hypertension, and many more.
  3. Consider Value-Based Care - Healthcare providers and organizations can also leverage value-based care initiatives such as Medicare's Value-Based Payment Modifier (VBPM) program. The VBPM program aims to incentivize providers to deliver high-quality, cost-effective care by rewarding those who meet or exceed performance standards and penalizing those who do not. By meeting or exceeding these standards, the provider can receive financial rewards, which can then be used to invest in further improving the care provided to patients with chronic conditions.
  4. Develop a Care Plan - Work with your patients to develop a personalized care plan that addresses their unique needs and goals. This plan should include strategies for managing chronic conditions, monitoring their symptoms, and tackling other health concerns. 
  5. Assign Care Coordination Staff - Designate a care coordinator(s) responsible for overseeing the CCM program and organizing care for eligible patients. As a healthcare provider, you may already have a staff member who can take on this role. If not, it's worth considering outsourcing your CCM program to a third-party vendor with the expertise and resources to manage the program effectively. Your care coordinator(s) should be a medical professional who has experience working with chronic conditions. They should also have good bedside manners and people skills to build trust and rapport with patients.
  6. Train and Empower Staff - The success of your program lies in the hands of your care coordinators and healthcare providers. It's imperative to equip them with the chronic care management training they need to achieve the program's objectives seamlessly. Every detail matters, from understanding the program's goals to mastering its workflows and documentation requirements. This step is significantly easier with a third-party team of medically trained care coordinators, who will use their expertise to support your facility throughout the process. 
  7. Implement Technology - Patient data management, appointment scheduling, billing, and care plan creation take significantly less time with the proper technology. Ideally, your CCM technology should integrate with your existing electronic health records (EHRs), patient portals, or other software. TimeDoc Health is a forerunner in this field, as the TimeDoc platform easily monitors patient progress, automates care planning, and significantly reduces the hours spent on chronic care management billing. 
  8. Monitor and Evaluate - Once you get your program off the ground, it's essential to monitor, evaluate, and improve it. Patient data regulations and CCM technology will only continue to evolve—so a stagnant CCM program won't work. Set key performance indicators (KPIs), such as patient engagement, medication adherence, and hospital readmission rates, to determine if your program is working as intended. Collect and analyze this data frequently to celebrate successes and identify growth opportunities.

Keep in mind that the specific steps for starting a CCM program may vary depending on your practice's needs and resources. Consider seeking guidance from other healthcare organizations or consultants with expertise in chronic care management to help you develop and implement a successful program.


What Are the Duties of Chronic Care Management? The Chronic Care Model Explained

CCM services are typically provided by a care team that includes physicians, nurses, and other healthcare professionals. The duties of chronic care management may involve the following:

  • Care Coordination - The care team works together to create a comprehensive care plan for each patient, taking into account their medical history, current health status, and individual needs and preferences. To illustrate, let’s use a chronic care model example—imagine a hypothetical patient, Naomi, who is receiving CCM for her diabetes. Her team coordinates with other healthcare providers, such as an endocrinologist or a podiatrist, to ensure that she receives appropriate and timely care. For example, if Naomi's care team identifies a need for a foot exam, they would coordinate with a podiatrist to ensure Naomi receives the necessary care.
  • Regular Follow-Ups - Naomi's care team schedules regular check-ins with her over the phone to assess her health status and make any necessary adjustments to her care plan. These follow-ups ensure that Naomi is receiving appropriate care and support between appointments. Naomi's care team regularly reviews her blood glucose logs and adjusts her treatment regimen accordingly to ensure optimal diabetes management.
  • Patient Education - During these follow-up calls, the care team educates Naomi about her diabetes, including symptoms to watch for and strategies for managing her condition. They give her information about healthy lifestyle habits, such as diet and exercise, that can improve her overall health. Naomi also receives reminders on the importance of monitoring her blood glucose levels regularly and adjusting her insulin doses accordingly.
  • Medication Management - The care team helps Naomi manage her medications. They ensure that she is taking the correct dosage at the appropriate times and monitoring for potential side effects or drug interactions. Naomi’s care team regularly reviews her medication regimen and makes any necessary adjustments based on her blood glucose readings.
  • Remote Monitoring - The advantages of remote monitoring become clearer every day, with recent studies suggesting that remote monitoring leads to lower hospitalization and mortality rates. Naomi's care team uses wearable devices and telemedicine visits to monitor her disease remotely. This type of monitoring can assist with identifying potential health issues before they become serious and allow for timely intervention. For example, if Naomi's blood glucose levels start to trend upward, her care team would be alerted and could intervene before she experiences a severe hyperglycemic episode.

Ultimately, the primary duty of CCM is to ensure that patients with chronic conditions receive the support and guidance they need to achieve their health goals. By taking this patient-centered approach and providing comprehensive care, you can help these individuals manage their conditions effectively and lead healthy, fulfilling lives.

What Is CMS Chronic Care Management?

The CMS started offering a groundbreaking program around 2014 to care for Medicare and Medicaid patients battling chronic diseases. Basic eligibility criteria for this program mandate that:

  • Patients have at least two chronic conditions that are expected to last for a minimum of 12 months or until the end of life.
  • Patients have a written care plan that is regularly reviewed and updated by their healthcare provider.

The CMS’s Chronic Care Management program aims to transform the healthcare landscape by providing comprehensive care and support for patients with chronic conditions. By offering financial incentives to healthcare providers who offer CCM services, the program encourages participation in this pivotal initiative.

While some facilities may have experienced initial challenges in navigating the program, many have since found it to be a valuable tool for improving care management and patient outcomes. Consider this case study on Dunbar Medical Associates, PLLC, a large primary care practice in West Virginia. Despite initial challenges, the practice recognized the program's potential to improve patient care and financial health, and they committed to making it work. 

To start, Dunbar hired a full-time chronic care management nurse to provide proactive outreach to patients. However, frustration set in when they realized their EHR did not efficiently document required information such as patient enrollment and care planning. The CCM nurse had to manually toggle between the EHR and Excel, making tracking highly inefficient and tedious. 

The solution? TimeDoc Health. TimeDoc's EHR-integrated CCM platform and services impressed the Dunbar team as they simplified documentation, increased patient engagement, and automated billing reports. In just under three months of using TimeDoc Health, Dunbar enjoyed such benefits as:

  • A remarkable increase in the number of patients receiving CCM services each month—a mere 50 to an impressive average of 450 patients. 
  • The ability to closely monitor the progress of each CCM patient in real-time and focus attention on non-completed patients. 
  • A revenue boost from $20k to $150k in annual reimbursement, with projected earnings of $225K the following year.

Along with these benefits, all Dunbar providers and clinical staff were able to easily navigate the “user-friendly” TimeDoc platform and calculate their time spent with CCM patients. Dunbar's Practice Manager, Nancee Barnette, summed it up nicely: “I feel strongly during the most challenging days upon us and ahead of us, chronic care management will be a means to care for our most vulnerable patients, as well as offer a source of revenue.”

Who Can Bill for CCM Services?

While clinical staff can provide CCM services, the billing must be done under the name of the supervising provider. According to the CMS chronic care management requirements, supervising providers can be any of the following:

  • Physicians
  • Advanced practice registered nurses
  • Physician's assistants
  • Clinical nurse specialists
  • Certified nurse midwives  

One important note—only one qualified healthcare provider can bill for CCM services in a given month. They can either take on the care management role for each patient or delegate it to another qualified provider. Additionally, the CMS allows care coordinators to provide services required for CCM, as long as it is done under the supervision of a physician or other qualified healthcare professional who bills for CCM. 

Can external companies perform the clinical staff portion of CCM for reimbursement purposes? They can, according to the latest from the CMS. A billing practitioner may engage external clinical staff to provide the clinical staff portion of CCM services as long as all the necessary rules for billing CCM to the Physician Fee Schedule are met. 

What Is the New CPT Code for Chronic Care Management?

The newest CPT code for CCM is 99491, which was established by the CPT Editorial Panel in 2019. To understand the need for this new code, let's examine the web of CPT codes providers commonly use for CCM:

  • 99490 applies when a patient has two or more chronic conditions expected to last a year or until the patient passes away. To use this code, clinical staff must spend at least 20 minutes per month coordinating and managing the patient's care under the direction of a physician or other qualified healthcare professional.
  • 99439 replaced HCPCS code G2058 in 2022 as an add-on to 99490. This code lets providers bill for an extra 20 minutes of clinical staff time—directed by a qualified healthcare professional—each calendar month after the initial 20 minutes have been captured by CPT code 99490.
  • 99491 is the newest CCM code. It is used when the billing practitioner—either a physician or non-physician practitioner (NPP)—does the same work as clinical staff in code 99490, but for at least 30 minutes. Clinical staff time does not count toward the 30-minute threshold for this code. 
  • 99437 is an add-on to 99491, as it is for each additional 30 minutes of health care time by a physician or NPP.
  • 99487 is reserved for complex CCM (aka CCCM), which involves moderate- to high-complexity medical decision-making. The physician or qualified healthcare professional must spend at least 60 minutes per month coordinating and managing the patient's care to use this code.
  • 99489 is an add-on to 99487, as it is for each additional 30 minutes of a physician or other qualified healthcare professional's clinical staff time. 

Below is a handy chart provided by the CMS that succinctly clarifies each code. Of note, Relative Value Units (RVUs) are a measure of the relative resources required to provide a service or procedure. Additionally, the RVU Update Committee (RUC) is an advisory group that provides recommendations on the valuation of medical services under the Medicare Physician Fee Schedule.

chart with CCM information

How Much Does Medicare Pay For Chronic Care Management?

The amount of reimbursement you'll receive for CCM depends on multiple factors, like the type of service, geographic location, any recent legislative updates, and more. With that in mind, below are some national average reimbursement rates for each of the CCM CPT codes in 2023. Please note that these calculations are for illustrative purposes only, and these numbers can vary and are not representative of what your practice may receive in reimbursement.

  • 99490 - CCM clinical staff first 20 minutes - $61.16
  • 99439 - CCM clinical staff each additional 20 minutes - $46.28
  • 99491 - CCM physician or NPP work first 30 minutes - $82.98
  • 99437 - CCM physician or NPP each additional 30 minutes - $58.52
  • 99487 - CCCM clinical staff first 60 minutes - $129.93
  • 99489 - CCCM clinical staff each additional 30 minutes - $68.76

To determine the national average reimbursement rates above, a calculation was performed using publicly available data from the CMS's Physician Fee Schedule. Specifically, the total Non-Facility RVUs and Malpractice RVUs were multiplied by the 2023 conversion factor of $33.06. 

Fortunately, RVUs for CCM saw significant increases in 2022 because the CMS adopted the recommended increases in assigned RVUs put forth by the RUC. These changes represent a critical shift in reimbursement strategy, with CMS prioritizing the accurate reflection of resources required to provide vital services like CCM. As a result, providers can expect to see higher reimbursement rates for each of the CCM CPT codes. For example, prior to the RVU increase, the reimbursement rate for code 99490 in 2021 was only $39.01—now, it's at $61.16, nearly a 60% increase.

To streamline the CCM billing process even further, you need automation. With TimeDoc Health, you can track patient engagement, document care coordination activities, generate compliant billing reports—and so much more.

TimeDoc Health: Making Every Minute Count in Your Chronic Care Management Workflow

At the heart of every great healthcare organization is a commitment to excellent patient care. With TimeDoc Health’s CCM services and EHR-integrated platform, that commitment is taken to the next level.

We understand that physician and clinical staff time is precious and must be spent with the utmost care and attention to detail. That's why we've designed an easy-to-use interface that seamlessly integrates with your patient charts. This allows providers to document patient activities directly from their charts without interrupting clinical workflows.

What other benefits can you look forward to with TimeDoc Health? 

  • Supplemental and flexible care coordination efforts from our team of experienced certified/registered medical assistants, should you need them
  • Less time spent on CCM billing with automated reports that instantly calculate charges using documented activities and then post them to your EHR
  • Comprehensive training sessions for your entire clinical staff on the TimeDoc platform and additional training as needed
  • A physician-created chronic care management template for each chronic disease that guides care coordinators through CCM services for every patient
  • Billing support for transitional care management (TCM), behavioral health integration (BHI), and complex CCM codes

At TimeDoc Health, we believe that patient outcomes should always come first. That's why we're committed to delivering not just financial security and predictability, but also unmatched satisfaction to both you and your patients. 

Are you ready to experience the TimeDoc Health difference? Request a demo today and take the first step towards a more efficient, effective, and satisfying healthcare practice.

How TimeDoc Supports Chronic Care Management

TimeDoc Health

Staff Augmentation

Many healthcare organizations do not have the capacity to provide the virtual care needed for chronic care management. These practices can utilize our team of medically trained care managers as a remote extension of their practice to coordinate care.

TimeDoc Health
TimeDoc Health

Enrollment Services

Enrollment services help you identify the best patients for your CCM program, and work to increase enrollment through direct patient contact. These services take care of educating patients, obtaining consent, and mailing out care plans, ensuring Medicare compliance.

TimeDoc Health
TimeDoc Health

Maintain Medicare Program Compliance

Monthly encounter summaries, patient consent, and care plans are stored to be easily accessed in our platform with PDFs pushed into your EHR to assist in case of a Medicare audit.

TimeDoc Health
TimeDoc Health

Automate Care Planning

Use our physician-created care plans or create your own templates to upload into our platform that synchronizes with your EHR to automatically fill patient data to streamline the care planning process. 

TimeDoc Health
TimeDoc Health

Reduce Documentation and Billing Time

Advanced EHR integration gives you the ability to document directly from the patient chart, streamlining end-of-month CCM billing with reports that automatically tabulate charges based on documented activities.

TimeDoc Health
TimeDoc Health

Increase Care Staff Efficiency

Dashboards give you real-time visibility into your program size, patient population, and care management productivity. Your care team can prioritize their patient panel by risk, minutes documented, active problems, and more. 

TimeDoc Health

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